Provider Demographics
NPI:1194078808
Name:CALCAMUGGIO, LISA (LISA CALCAMUGGIO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CALCAMUGGIO
Suffix:
Gender:F
Credentials:LISA CALCAMUGGIO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:CALCAMUGGIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISA CALCAMUGGIO
Mailing Address - Street 1:2570 STERNS ROAD
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144
Mailing Address - Country:US
Mailing Address - Phone:419-343-6816
Mailing Address - Fax:
Practice Address - Street 1:2570 STERNS RD
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9414
Practice Address - Country:US
Practice Address - Phone:419-343-6816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI39833700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist